The Development of a Knowledge Tool: For Rapid Assessment of Palliative Medicine

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The Development of a Knowledge ToolFor Rapid
Assessment of Palliative Medicine End of Life
Knowledge in Medical Students

• Alyson Brodeur MD

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• Pippa Hall
• Lynda Weaver

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Objectives

• Develop a quick easy to use assessment tool
• Important for tool to be specific and to have
  ecological validity (content relative to medical
  students)
• Identify possible uses for tool
• needs assessments
• evaluate educational initiatives
• stimulate discussion

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The Palliative Care Quiz for Nursing (PCQN)

• Ross MM McDonald B McGuinness J. The
  palliative care quiz for nursing (PCQN) the
  development of an instrument to measure nurses
  knowledge of palliative care. Journal of
  advanced nursing. 199623126-137.
• Dieckmann L Zarit J Gatz M. The alzheimers
  disease knowledge test. The Gerontologist. 1988
  28(3) 402-407.
• Pratt CC Wilson W. Benthin A. Schmall V.
  (1992). Alcohol problems and depression in later
  life Development of two knowledge quizzes.
  www-distance.syr.edu/ageans2.html

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Development - Stage One

• Advisory committee - To establish
• key knowledge areas
• determine appropriate format level of
  difficulty
• generate items
• Ontario palliative undergraduate network - common
  educational objectives for students in an
  undergraduate medical curriculum - draft report
  2004

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Development - Stage One

• Literature Review (ongoing)
• current knowledge tools/quizzes
• Databases Cinahl Medline
• Search Terms
• (palliative or hospice or terminal care or
  terminal illness or dying or end of life) AND
  ( (curriculum or education evaluation or
  knowledge evaluation) OR(knowledge or education
  need assessment or tool or tools or test or
  testing or questionnaire) ) AND ( (medical
  resident or medical student) OR (undergraduate
  and (medicine or medical) )

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Development - Stage One

• Biswal BM Zakaria A Baba AA Jaafar R.
  Assessment of knowledge attitude and exposure to
  oncology and palliative care in undergraduate
  medical students. Medical journal of malaysia.
  200459(1)78-83.
• Burge F McIntyre P Kaufman D Cummings I
  Frager G Pollett A. Family medicine residents
  knowledge and attitudes about end-of-life care.
  Journal of palliative care. 200016(3)5-12.
• Dionne L Dionne A. Global exchange a
  questionnaire to medical students on palliative
  care and euthanasia. Journal of palliative care.
  199612(2)39-46.

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Development - Stage One

• Fischer SM Gozansky WS Kutner JS Chomiak A
  Kramer A. Palliative care education an
  intervention to improve medical residents
  knowledge and attitudes. Journal of palliative
  medicine. 20036(3)391-399.
• Jackson WC Connor PD Tavernier L. Antemortem
  care in an afternoon a successful four-hour
  curriculum for third-year medical students.
  American journal of hospice palliative care.
  200219(5)338-342.
• Oneschuk D Fainsinger R Hanson J Bruera E.
  Assessment and knowledge in palliative care in
  second year family medicine residents. Journal of
  pain and symptom management. 199714(5)265-273

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Development - Stage Two

• Consultation beyond the advisory group
• Assessment
• small group (8-12 individuals)
• palliative medicine physicians fellows nurses
  and pharmacists
• assessed knowledge tool on two different
  occasions
• goal - assess clarity relevance level of
  difficulty accuracy
• end result two questions significantly changed

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Development - Stage Three

• Test-Piloting
• Family Medicine academic half-day
• PGY-1 PGY-2
• Response rates
• PGY-1 100 (n 17)
• PGY-2 70 (n 8)
• Mean scores (out of 6)
• PGY-1 3.4
• PGY-2 2.3

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Residents Assessment of Tool

• The majority of residents thought the quiz was a
  fair tool for assessing fourth year medical
  students knowledge
• Most residents assessed the level of difficulty
  as average
• 61 average
• 35 difficult
• 4 easy

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Development - Stage Three

• Test-piloting
• University of Ottawa - fourth year medical
  students
• Location MCCQE review lecture
• Class size 125
• 90 students in attendance
• Response rate 67
• Incomplete 5
• Assessment based on 50 responses

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Medical Students - Year 4

• Mean Score 1.8 Mode 1.0

Correct
Question Number
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Question One

• Mrs. X is taking Long-Acting Morphine tablets 30
  mg by mouth every 12 hours for her pain which
  has been well controlled. She is now dying and
  unable to take anything by mouth. The
  appropriate change in medication should be
• a) 10 mg sc q4h
• b) 5 mg sc q4h
• c) 5-10 mg sc q4h prn only
• d) crush the tablets dissolve them in water
  and administer same medications bucally

38 of students identified the correct answer
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Question Two

• Which of the following opioid medication has
  serious consequences if given for chronic pain
  management
• a) methadone
• b) hydromorphone (Dilaudid)
• c) fentanyl patch (Duragesic)
• d) meperidine (Demerol)

56 of students identified the correct answer
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Question Three

• Sally has developed signs of toxicity on morphine
  (some confusion hallucinations myoclonus) and
  the cancer in her bones is still causing pain.
  She is taking 200 mg of morphine per day. To
  improve her symptom control you can
• a) switch to another strong opioid such as
  hydromorphone
• b) add a different long acting opioid such as
  the fentanyl patch
• c) add a neuroleptic such as haloperidol
• d) (a) and (c)

28 of students identified the correct answer
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Question Four

• Joe was prescribed an opioid for severe pain due
  to metastatic prostate cancer 2 days ago. The
  medication has made him feel very nauseated. The
  most appropriate antiemetic which has its main
  effect on the chemoreceptor trigger zone is
• a) dexamethasone (Decadron)
• b) haloperidol (Haldol)
• c) dimenhydrinate (Gravol)
• d) scopolamine patch

0 of students identified the correct answer
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Question Five

• Mr. Y. has end-stage COPD. Despite optimum
  medical management he remains short of breath.
  To improve his symptom control you can start
• a) a fan for his face
• b) an opioid (e.g. morphine)
• c) a neuroleptic (e.g. chlorpromazine)
• d) all of the above

38 of students identified the correct answer
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Question Six

• You have just written a prescription for
  hydromorphone (Dilaudid) for a patient. You must
  also write a prescription for a laxative. The
  best choice is
• a) a stool softener such as docusate sodium
• b) an enema if needed
• c) a bowel stimulant such as senna derivatives
• d) a glycerine suppository

18 of students identified the correct answer
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Development - Stage Four

• Reassess
• Item Difficulty
• Item Clarity
• Total number of Items
• Determine
• Item Discrimination
• Face Validity
• Test-retest Reliability

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Development - Stage Four

• Determine if responses vary in accordance to
  level of education and experience
• Further comparison of test results for family
  medicine residents and fourth year medical
  students
• Identify frequent misconceptions